Victoria A. Walker, MD, Department of Internal Medicine, Division of Geriatric Medicine, Duke University Medical Center, Durham, North Carolina, USA.
Heather E. Whitson, MD, Department of Internal Medicine, Division of Geriatric Medicine, Duke University Medical Center, Durham, North Carolina, USA.

Smoking is the leading cause of preventable death worldwide. Though older adults are the segment of the population least likely to smoke, they incur significant morbidity and mortality from tobacco use and can benefit from quitting. Older smokers have beliefs regarding smoking and motivating factors for cessation that differ from younger adults. Clinicians should understand these unique factors and can then use strategies to assist the older adult in smoking cessation.
Key words: smoking cessation, tobacco, epidemiology, older adults, prevention.

Katherine R. Schlaerth, MD, Fellow, American Academy of Pediatrics; Fellow, American Academy of Family Practice; Fellow, Pediatric Infectious Disease Society; Associate Professor, Department of Family Medicine, Loma Linda University School of Medicine, Loma Linda, California; Associate Professor Emeritus, Departments of Family Practice and Pediatrics, University of Southern California School of Medicine, Los Angeles, California, USA.

Most practitioners assume that the use of illegal or “street” drugs is confined to the young. However, a recent phenomenon has been the use of such drugs by individuals above the age of 50. Social trends play a part: many older addicts began using in the 1960s. Others share the use of illegal drugs with other family members as a mode of family recreation. The latter trend is probably more common in inner cities where drugs are more easily obtained. Older men are twice as likely to use illegal drugs as are older women, though the latter outnumber the former demographically. Many illegal drugs, especially cocaine, methamphetamines, and even marijuana have cardiovascular effects that are especially dangerous when they occur in older individuals who may already have underlying cardiovascular disease. Practitioners must be vigilant about querying patients about their use of illegal drugs, no matter what their age, and especially if cardiovascular illness is involved.
Key words: older adults, illegal drugs, cardiovascular disease, cocaine, methamphetamines.

Ann Schmidt Luggen, PhD, GNP, Professor Emeritus, Northern Kentucky University, Highland Heights, Kentucky, USA.

The number of older adults who drink to excess is not known, partly because primary health practitioners seldom screen for this problem. The signs of alcohol abuse are vague prior to late-stage liver failure and many of them are attributed to normal aging. Two types of alcohol dependence are commonly seen in older adults: type I is a late-onset alcohol dependence in which depression, chronic illness, or life changes such as retirement precipitate drinking, while type II is mainly genetic and reflects lifelong drinking that has not been previously identified by health professionals. Pharmacologic agents such as naltrexone and acamprosate have been shown in a number of clinical trials to be useful in care. A great many others are still in testing phases. Nonpharmacologic management is also effective, especially when teamed with drug therapy. Some of these are cognitive behavioural therapy, motivational enhancement therapy, and counselling that the primary care physician can do in the office, also known as the brief intervention approach. There is much that can be done if alcohol dependence is recognized.
Key words: alcohol, aging, older adults, dependence, liver disease.

Christopher Frank, MD, CCFP, Department of Medicine, Division of Geriatrics, Queen’s University, Kingston, ON.

Skin ulcers are common among older adults, especially those in hospital or in long-term care facilities. Prevention of ulcers is important in all clinical settings. Clarifying the cause(s) and exacerbating factors is the first step in management. Pressure and venous insufficiency are the most common causes among older adults. Poor nutrition, edema, arterial insufficiency, and anemia may impair wound healing. Adequate debridement and cleaning is important to decrease infection risk and to promote healing. The choice of dressings depends on the needs of the individual wound but should emphasize the provision of a moist wound environment. Options for dressings are summarized.
Key words: skin ulcers, treatment, wound healing, older adults, pressure ulcers.

Kannayiram Alagiakrishnan, MD, MPH, FRCPC, ABIM, Associate Professor, Division of Geriatric Medicine, Department of Medicine, University of Alberta, Edmonton, AB.

Postural and postprandial hypotension are common conditions among older adults. They are causes of dizziness, syncope, and falls in older people. These conditions may result in significant morbidity, a decrease in function, and mortality. Dysregulation of blood pressure in older adults can result in postural and postprandial hypotension. Routine screening for these conditions is easy to perform and helps to diagnose and manage them appropriately. Management includes a combination of nonpharmacological and pharmacological interventions.
Key words: postural hypotension, postprandial hypotension, management, blood pressure, older adults.

Pascal Jean-Pierre, PhD, Department of Radiation Oncology, Department of Family Medicine, University of Rochester Medical Center, Rochester, New York, USA.
Gary Morrow, PhD, MS, Department of Radiation Oncology, Department of Psychiatry, University of Rochester Medical Center, Rochester, New York, USA.

Fatigue due to cancer and its treatments is a highly prevalent and debilitating symptom experienced by many patients. This symptom is often present prior to a pathologically confirmed diagnosis of cancer and can be experienced both during and for considerable periods after treatment. Oncology professionals are becoming more cognizant of the impact of cancer-related fatigue on key aspects of patients’ psychosocial performance, cognitive functioning, and overall quality of life. This paper discusses the importance of cancer-related fatigue, the challenges involved in assessing this debilitating symptom among cancer patients, and the influence of researchers’ conceptualization of this symptom on the characteristics of the measures developed to assess it. Strategies to facilitate differential diagnosis of cancer-related fatigue are also presented and discussed.
Key words: cancer-related fatigue, assessment, measurement dimension, older adults, quality of life.

Deepali Kumar MD, MSc, FRCP(C), Consultant, Infectious Diseases, Immunocompromised Host Service, University Health Network; Assistant Professor, University of Toronto, Toronto, ON.

The incidence of cancer continues to increase, and many persons receiving treatment for cancer are older adults. Fever in older adults with cancer can be an emergency. Any patient with fever and neutropenia should be given antibiotics as soon as possible. In addition to the immune senescence associated with aging, individuals with cancer have immunodeficiencies specific to their underlying malignancy, and these predispose them to specific infections. Older adults are also at higher risk of the complications of chemotherapy, including infections. Prompt evaluation and judicious management of the febrile cancer patient can reduce morbidity and mortality. The following review considers an approach to the etiologies and evaluation of fever in cancer including the infectious and noninfectious causes.
Key words: fever, cancer, older adults, antibiotics, neutropenia.

David R. Staskin, MD, Department of Urology, New York Presbyterian Hospital, Weill-Cornell Medical College, New York, NY, USA.
Edward Zoltan, MD, Division of Urology, Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA, USA.
Alan J. Wein, MD, Division of Urology, Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA, USA.

Older adults have a high prevalence of urinary incontinence. Among the older adult population, many nonurinary pathological, anatomical, physiological, and pharmacological factors may serve as comorbidities in the development of incontinence. The treating physician must appreciate potentially reversible pathologies. Older adults frequently are prescribed several drugs; therefore, it is important to consider drug-drug metabolic interactions. Age-associated changes may affect pharmacological actions of the drug. Antimuscarinic therapy has been proven efficacious and represents the first line of pharmacologic therapy for overactive bladder (OAB). The selection of an antimuscarinic agent for the management of an older individual presenting with OAB is limited by the natural condition of the aging body and by the side effects associated with antimuscarinics as a class and the specific agents themselves.
Key words: urinary incontinence, antimuscarinics, older adult, frail older adult, geriatrics.

Abi Rayner, MD, MPH, Buller Medical Service, Westport, New Zealand.

Hallucinations and delusions increase the risk of developing dementia, delirium, functional impairment, and of death. The differential diagnosis includes isolated hallucinations, delirium, depression with psychotic symptoms, late-onset schizophrenia, and unrecognized dementing disorder, including Lewy Body disease and frontotemporal dementia. Optimum management requires diagnosis, assessment of the goals of treatment, and understanding the risks and benefits associated with psychoactive medications. Atypical neuroleptics are appropriate first-line agents for most patients with dementia and psychotic symptoms. Response to medications is modest and a second agent (including acetylcholinesterase inhibitors, antidepressants, and anticonvulsants) may be necessary to reduce behaviour to acceptable levels. In addition, decline in cognitive status and increased risk of cerebrovascular events and death are associated with the use of antipsychotic medications. Change in functional status and time alter the impact of behavioural symptoms. Periodic reassessment and reduction of medication dosage over time appears safe, usually without re-emergence of symptoms.
Key words: psychotic symptoms, older adult, dementia, antipsychotics, behavioural disturbance.

The accredited CME learning activity based on this article is offered under the auspices of the CE department of the University of Toronto. Participating physicians are entitled to one (1) MAINPRO-M1 credit by completing this program, found online at www.geriatricsandaging.ca/cme

Andrew McIvor MD, MSc, FRCP, Professor of Medicine, McMaster University; Firestone Institute for Respiratory Health, St Joseph’s Healthcare, Hamilton, ON.

At present, some 750,000 Canadians are known to have chronic obstructive pulmonary disease (COPD). This number is believed to represent the tip of the iceberg, as COPD is often only diagnosed in the advanced stage. Respiratory symptoms or a previous smoking history are common among older adults yet they seldom trigger further assessment for COPD. Objective demonstration of airflow obstruction by spirometry is a simple procedure, even in older adults, and is the gold standard for diagnosis of COPD. Early intervention with routine nonpharmacological management includes partnering with the patient and family, providing education, smoking cessation, vaccination, collaborative self-management, and advice on exercise and pulmonary rehabilitation. Anticholinergic inhalers remain the gold standard for optimal bronchodilation and dyspnea relief in COPD, and new long-acting agents have underpinned new treatment algorithms, improving quality of life and exercise capacity as well as reducing exacerbations. For those with advanced disease, recent trials have reported further benefits with the addition of combination inhalers (inhaled corticosteroid and long-acting B2-agonist) to core anticholinergic treatment. Physicians and patients can expect a promising future for COPD treatment as significant advances in management and improved outcomes in COPD are now being made.
Key words: chronic obstructive pulmonary disease, older adults, spirometry, diagnosis, management.